CASE STUDY OF

MRS. X
A 62 years old women was admitted to
the emergency room complaining of
cough and difficulty of breathing
which is the reason for her sleep
disturbances. She has a BP of 160/90
and RR of 24bmp upon checking her
vital signs. The physician ordered o2
cannula therapy and captopril
sublingual stat. She was diagnosed
with community acquired pneumonia
and hypertension
Studying this diseases where the patient
diagnosed will hopefully give us student
nurses or future nurses, together with
the rest of the health-care team, some
more information regarding the disease
and its proper management, and the
different nursing responsibilities
that should be taken into consideration
when faced with his kind of case.
• Biographic Data
– Name: Leonilla Racab Llantos
– Address: San Isidro, San Jorge Samar
– Age: 62 years old
– Sex: Female
– Mental Status: Alert, Conscious, Coherent
– Occupation: Farmer
– Religion: Roman Catholic
– Health Care Financing: Philhealth
– Usual Source of Medical Care: Philhealth and
children
– Status: Live in with Melano Arom G. Ros
• Chief of Complaint
– Cough for 3 days
– Fever
– Fatigue
– Dob
– Sleeping disturbances
• History of present illness
– When did the symptoms start?
• 3 days ago
– Onset of symptoms? Gradual/ Sudden
• Sudden
– How often does the problem occur
• Every night before going bed which causes sleep disturbances
– Exact location of the distress
• Chest
– Activity in which the client was involved that the
problem occurred
• Nag lalampaso
• Nag uma
• Nag lalaba
• Past Medical History
– Childhood Illness
• Fever, Cough, Colds (Common Childhood Illnesses)
– Childhood Immunization
• No immunization in her time
– Allergies
• None
– Accident or Injury
• None
– Hospitalization for serious illness
• Last hospitalization was September 27 because of
hypertension. 2 weeks from being admitted again
• Family History
– Fathers Name: Gregorio Llantos
– Mothers Name: Lolita Llantos

Patient has a history of

cardiovascular disease for both
parents died in stroke
• Lifestyle
She never ever tried smocking
Occasionally drinks alcohol for social purposes
She seldom exercise
Spends a lot of time farming and doing house
chores
She is emotionally and financially stressed
because her grandchild is in hospitalization
because of dengue fever
Her diet is eating a mixture including daily fruit
and vegetables
Sleep / Rest patterns
• Sleeps at around 7pm and wakes up at 5am, but
recently she wakes up at middle of the night because of
difficulty on breathing. Sometimes couldn’t sleep
because of fatigue.
Activity of daily living
• Every morning she thanks God for another day
• She do house chores before doing farming
• Whenever she has free time she reads bible
• She cooks food for her family then do their laundry
• Sleeps early for she believes that she need a lot of
energy for the next day of work
 ANATOMY
AND
PYSHIOLOGY
• Respiratory System
The main functions of the respiratory
system are to obtain oxygen from the
external environment and supply it to the
cells and to remove from the body the
carbon dioxide produced by cellular
metabolism. The respiratory system is
composed of the lungs, the conducting
airways, the parts of the central nervous
system concerned with the control of the
muscles of respiration, and the chest wall.
The chest wall consists of the muscles of
respiration—such as the diaphragm, the
intercostal muscles, and the abdominal
muscles—and the rib cage.
 Alveoli are tiny balloon shaped structures and are the smallest
passageway in the respiratory system. The alveoli are only one cell
thick, allowing the relatively easy passage of oxygen and carbon
dioxide (CO2) between the alveoli and blood vessels called capillaries.
Alveoli are lined by a fluid layer known as surfactant which maintains
the shape and surface tension of the air sac. By maintaining surface
tension, there is more surface area through which oxygen and CO2
molecules can pass. Alveoli are the endpoint of the respiratory system
which starts when we inhale air into the mouth or nose. The oxygen-
rich air travels down the trachea and then into one of the two lungs
via the right or left bronchus. From there, the air is directed through
smaller and smaller passages, called bronchioles, past the alveolar
duct, until it finally enters an individual alveolus. It is at this junction
that oxygen molecules diffuse through a single cell in an alveolus and
then a single cell in a capillary to enter the bloodstream. At the same
time, CO2 molecules, a byproduct of cellular respiration, are diffused
back into alveolus where they are expelled out of the body through
the nose or mouth.
• Cardiovascular System
The cardiovascular system is sometimes ca
lled the circulatory system. It consists of
the heart, which is a muscular pumping
device, and a closed system of vessels
called arteries, veins, and capillaries. As
the name implies, blood contained in
the circulatory system is pumped by the
heart around a closed circuit of vessels
as it passes again and again through the
various "circulations" of the body.
Blood vessels are the channels or conduits
through which blood is distributed to body
tissues. The vessels make up two closed
systems of tubes that begin and end at the
heart. One system, the pulmonary vessels,
transports blood from the right ventricle to
the lungs and back to the left atrium. The
other system, the systemic vessels, carries
blood from the left ventricle to the tissues
in all parts of the body and then returns the
blood to the right atrium. Based on their
structure and function, blood vessels are
classified as arteries, capillaries, or veins.
Arteries carry blood away from the heart. Pulmonary arteries transport blood that
has a low oxygen content from the right ventricle to the lungs. Systemic arteries
transport oxygenated blood from the left ventricle to the body tissues. Blood is
pumped from the ventricles into large elastic arteries that branch repeatedly into
smaller and smaller arteries until the branching results in microscopic arteries
called arterioles. The arterioles play a key role in regulating blood flow into the
tissue capillaries. About 10 percent of the total blood volume is in the systemic
arterial system at any given time. Veins carry blood toward the heart. After blood
passes through the capillaries, it enters the smallest veins, called venules. From
the venules, it flows into progressively larger and larger veins until it reaches
the heart. In the pulmonary circuit, the pulmonary veins transport blood from the
lungs to the left atrium of the heart. This blood has high oxygen content because
it has just been oxygenated in the lungs. Systemic veins transport blood from the
body tissue to the right atrium of the heart. This blood has reduced oxygen
content because the oxygen has been used for metabolic activities in the tissue
cells. Because the walls of the veins are thinner and less rigid than arteries, veins
can hold more blood. Almost 70 percent of the total blood volume is in the veins
at any given time. Medium and large veins have venous valves, similar to the
semilunar valves associated with the heart that help keep the blood flowing
toward the heart. Venous valves are especially important in the arms and legs,
where they prevent the backflow of blood in response to the pull of gravity.
 Capillaries, the smallest and most numerous o
f the blood vessels, form the connection between
the vessels that carry blood away from the heart
(arteries) and the vessels that return blood to the
heart (veins). The primary function of capillaries is
the exchange of materials between the blood and
tissue cells Capillary distribution varies with the
metabolic activity of body tissues. Tissues such as
skeletal muscle, liver, and kidney have extensive
capillary networks because they are metabolically
active and require an abundant supply of oxygen
and nutrients.
PATHOPHYSIOLOGY
 S. Pneumonia

Microorganism enters the nose

(Nasal Passages)

Passes through the larynx, pharynx, trachea

Affects both airway and lung parenchyma

Airway Lung Invasion

Infiltration of bronchi Flattening of epithelial cells

Infectious organism lodges Macropaghes and

leukocytes

Stimulation in bronchioles Narrowing of air passage

Mucos and phlegm
production
Increase pyrogen in the body Alveolar collapse Difficulty of breathing

Fever Decreased Oxygen delivery to the Coughing

tissues

Body will compensate

Arteries will constrict Increase BP

 LAB FINDINGS
• CHEST X-RAY RESULTS
– There is Basal haziness, heart is not enlarged, great vessels are normal, media sternum
and diaphragmatic leaflets are normal, clear sulci, trachea at midline, bony thorax and
surrounding soft tissues are normal

• HEMATOLOGY RESULTS

Result Normal
HCT 41.89g/L 40- 42 g/L
RBC 4.67g/L 4.7- 6.1 g/L
HEMOGLOBIN 14.11g/L 13- 17 g/L
WBC 8.82g/L 4.8- 10.8 g/L
LYMPHOCYTES 31.6% 19- 48%
PHYSICAL ASSESSMENT
FINDINGS

TEMPERATURE 37.3C

PR 119bpm

RR 24bpm

BP 160/90mmHg
I. The Skin Upon II. The Nails
inspection, the The nails of our patient
patient’s skin was were intact and well
warm to touch, trimmed. The patient
slightly moist and has pinkish nail beds
smooth. There was and is smooth in
no presence of texture. Her capillary
lesion. When we test refill time was 2
her skin for mobility seconds and has a
and turgor, skin convex curvature of
rapidly resumes its fingernail plate. No
original shape after lesions were noted
pinching. around her fingernails
and toenails.
III. The Head and Skull
The Skull was
normocephalic and had
symmetrical facial
features. There were no
deformities noted such as
masses, bulges and
tenderness upon
palpation. There was
symmetrical facial
expression when the group
asked the patient to raise
her eyebrow, puff her
cheeks, smile and frown
and close her eyes tightly
IV. The Hair
Our patient has a
short gray hair due to
aging, slightly dry, and
evenly distributed. No
presence of infection
or any infestations
noted upon inspection
at the back of the ears
and along the hairline
in the neck. Hair on
the body was fine and
evenly distributed.
V. The Eyes
Both eyes were symmetrical upon
inspection; it can follow the direction of
our finger when we test her visual
acuity. The patient’s eyebrows were
evenly distributed. It was symmetrically
aligned and has equal movement.
Eyelashes curled slightly outward. The
eyelid on the other hand has no
discharges and discoloration. The sclera
on both eyes was yellow and clear, irises
are black and round. Pupils are equally
round, reactive to light and constrict
simultaneously with 2mm in size when
passed by a light. The Conjunctivas are
pinkish in color. There was no
tenderness noted upon palpation of the
lacrimal duct. The patient was able to
see objects in periphery when we test
her ocular eye movement.
VI. The Ears
Symmetrical auricles on both
ears were noted. Pinnas were in
line with the outer canthus of
her eyes. There was no
tenderness noted upon
palpation. Auricle had the same
color with the facial skin. Thus,
it is firm and non tender. The
external canal of her ear has no
discharges, inflammation nor
impacted cerumen noted upon
inspection. Ears were elastic
and coils back to its original
shape after being folded.
Patient was able to hear and
respond to a normal tone
VII. The Nose
No discharges noted upon VIII. The Mouth
inspection. Nasal flaring Lips are pail in color,
was noted upon early
monitoring of the vital dry lips; gums are
signs. Both nostrils are pinkish in color, tongue
present, and no tenderness
and masses or nodules is located in the
noted upon palpation. The midline, Uvula and
mucosa is pinkish with hair.
Thus, no tenderness on tonsils are not
sinuses noted upon inflamed and gag
palpation. There was good
patency on both nasal reflex is present.
cavities as the group
instructed the patient to
occlude of her nares and
breathe.
IX. The Neck
The patient’s neck has no
evident masses, unusual
swelling, or any pulsations.
Upon letting her neck move
such as flexing, extending,
right and left rotation, and
hyperextension, she was
able to move it easily
without pain or discomfort.
The thyroid was not visible
upon inspection and is
smooth, without nodules
and masses
X. The Thorax and Lungs
The thorax is symmetrical
from posterior and lateral
views. There was no
presence of masses or
tenderness upon
palpation. At the early vital
sign monitoring, the
respiratory rate of the
patient was 24 cycles per
minute, use of accessory
muscles were noted.
Increase tactile fremitus
noted upon percussion.
There was presence of
crackles upon auscultation.
Rapid shallow breathing
pattern was also noted.
 XII. The Abdomen
XI. The Heart Upon inspection, there no
The heart sounds are distinct scars or lesions noted. There
and regular with the rate of are no evident signs of
119beats per minute. The infection of the umbilicus
point of maximal impulse is such as redness, pus
best heard at the left mid formation, discoloration or
clavicular line, 5th intercostal swelling. No abdominal
space distention noted.
 EXTREMETIES:

XIII. Upper Limb XIV. Lower Limb

The patient has equal There were no
strength on both deformities noted on
upper extremities. both legs. Her legs and
Full range of motion knees can do all the
was observed when range of motion such
asked to move her as extending and
arms in a circular
flexing without feeling
motion. There was no
of discomfort.
presence of swelling
or deformity.
NURSING CARE
PLAN
 Assessment:
• Subjective:
Makuri guminhawa nalilipngaw ako”
• Objective:
RR: 24bpm
Crackles upon auscultation
Nasal flaring noted
Rapid and shallow breathing
Use of accessory muscles
Nursing Diagnosis
 Planning
• At the end of nursing intervention the patient
will be able to demonstrate increased in
perfusion
 Intervention
• Monitor Vital signs
To establish a baseline data
• Provide quite and calm environment
To conserve energy that could lower the tissue oxygen
demand
• Encourage to avoid doing strenuous activities
To avoid using too much energy that could increase
oxygen demand
• Encourage deep breathing exercise
To promote full expansion of the lungs and to
decrease tension level
Dependent:
• Administer prescribed medication
To mobilize secretion in the lungs that could help
in the oxygen transportation
• Administer oxygen when necessary as
prescribed by the physician
To compensate to the decreased oxygenation in
the lungs
 Evaluation
• At the end of nursing intervention the patient
was able to determine increased in perfusion
 Assessment:
• Subjective:
Makuri guminhawa ma’am”
• Objective:
RR: 24bpm
Crackles upon auscultation
Nasal flaring noted
Rapid and shallow breathing
Use of accessory muscles
Nursing Diagnosis
increased
 Planning
• After hours of nursing intervention patient will
experience secretions effectively and the RR
will decrease from 24bpm to normal range
 Intervention
• Asses rate or depth of respirations and chest
movement
Tachypnea, shallow respirations are usually present
• Elevate haed of bed and change position
frequently
Promotes lung expansion
• Assist with frequent deep breathing exercises
Deep breathing facilitates lung expansion of the lungs
and smaller airways
• Encourage increase in fluid intake
Fluids aids in mobilization and expectorations of
secretions
Dependent:
• Administer prescribed medication
Physician would prescribe meds with
bronchodilating effect and anti inflammatory
action, and drug for the infection
• Administer oxygen when necessary as
prescribed by the physician
To compensate to the decreased oxygenation in
the lungs
 Evaluation
• After hours of nursing intervention the patient
expectorated sections effectively and RR
decreased from 24bpm to normal range
 Assessment:
• Subjective:
Pera naako ka adlaw diri natutuhay it katurog
danay pa ngani dre naak nahihingaturog”
• Objective:
Restlessness at night noted
Tiredness noted
Nursing Diagnosis
Sleep deprivation r/t difficulty of breathing
 Planning
• After hours of nursing intervention patient will
identify individually appropriate interventions to
promote sleep and verbalize understanding of
sleep and verbalize understanding of sleep
disorder and report improvement in sleep and
rest patterns
 Intervention
• Determine client’s usual sleep pattern and
expectations
Provides comparative baseline
• Review current medications and their effect on
sleep suggesting modifications in regimen
Some medications are found to interfere sleep
• Instruct in relaxation techniques, music therapy,
meditation, and so forth
To decrease tension and prepare for rest or sleep
• Provide calm, quite environment and manage
controllable sleep-disrupting factors
To promote readiness for sleep, specially during right
Dependent:
• Administer prescribed medication or sleeping
medications
If non-pharmacological intervention is not enough
• Administer oxygen when necessary as
prescribed by the physician
To compensate to the decreased oxygenation in
the lungs
 Evaluation
• After hours of nursing interventions patient
identified individually appropriate interventions
to promote sleep and verbalized understanding
of sleep disorder and report improvement in
sleep and rest position
DRUG STUDY
AZITHROMYCIN